Thursday, December 15, 2016

The Republican congressional leadership appears to be determined
to move forward with a high-risk “repeal, delay and replace” plan, very early
in the new 115th Congress to repeal (at least on paper) the
Affordable Care Act’s key coverage provisions—Medicaid expansion, subsidies to
make private insurance sold through the exchanges affordable, the individual
and employer mandates, and the taxes to pay for coverage—by a simple majority
vote, while delaying when the repeal would go into effect to give them time to
come up with a replacement.

The problem is that this isn’t likely to work, not without
disrupting care for millions. As I
point out in a commentary The
Demise of the Affordable Care Act? Not
So Fast, published online on Tuesday in the Annals of Internal Medicine, I think it is magical thinking to
believe that one can repeal the ACA, delay the repeal from going into effect,
avoid loss of coverage, and then replace the ACA with something that keeps the
popular parts while jettisoning the unpopular ones.

Much more likely, according to many independent and
non-partisan studies, the result of “repeal, delay and replace” will be that many
millions of Americans will lose their coverage as early as 2017, and many more if the ACA is full repealed without
an alternative that offers comparable coverage.

So many, in fact, that I found from the studies that there
must be at least 50 ways you could lose
your health insurance if the ACA is repealed (my apologies to songwriter
Paul Simon). Under ACA repeal, you could
lose coverage if:

You are the one of nearly
59 million who would lose coverage if the ACA is fully repealed.

You
are a survivor
of domestic or sexual violence, which often was counted as a
pre-existing condition before the ACA, making you ineligible for coverage. You
could also lose the ACA-mandated coverage for interpersonal domestic violence
screening and counseling.

You
are a pregnant woman who has a medical need for
gestational diabetes screening, an ACA-required benefit that could be taken
away.

You
are a sexually
active woman who benefits from the ACA-required coverage of STI
counseling on sexually transmitted infections (STIs), which can reduce risk
behaviors in patients; for high-risk human papillomavirus (HPV) DNA testing
every three years, regardless of Pap smear results; for HIV screening and
counseling; and for contraceptive counseling.

You
are a sexually
active man who benefits from HIV screening and counseling and STD screening,
benefits which may no longer be offered if the ACA is repealed.

You
are in a red
state that has expanded Medicaid because ACA repeal could cut off
funding for the “more than 2.5 million people in GOP-represented states [who
were] were enrolled in Medicaid through the expanded eligibility” created by
the ACA.

You
are one of the over 39
million seniors who have received no-cost preventive services guaranteed by the ACA, like “flu shots,
tobacco cessation counseling, as well as no-cost screenings for cancer,
diabetes and other chronic diseases” and “annual wellness visits wellness visit
so they can talk to their doctor about any health concerns” at no out-of-pocket
cost to you.

You
are older but not yet Medicare age,
because if insurers are again allowed to charge older people 5 or 6 times more
than younger ones (the ACA limits it to no more than 3 times more), your
premiums in the individual market will go up.

You
are one of the 137
million people (55.6 million women, 53.5 million men, and 28.5 million
children) who have received no-cost coverage for preventive services from
private insurers since the ACA’s required coverage of such services went into
effect.

You
are a gun
violence victim, because the ACA “has brought coverage to tens of
thousands of previously uninsured shooting victims, often young
African-American men, who, once stabilized in emergency rooms, missed out on
crucial follow-up care and have endured unremitting effects of nerve injuries,
fractured bones, intestinal damage and post-traumatic stress disorder.”

You
are LGBT, because the ACA protects you from discrimination in coverage.

You
live
in a “red” (Republican leaning) state
because you are more likely to be at risk of losing coverage under the ACA and your
state will have fewer state resources to help you keep it, compared with “blue”
[Democratic-leaning] states that have fewer people at risk, and more resources
to maintain coverage for those who are.

You
don’t
have a college degree, since an
estimated 80 percent of adults at risk of becoming uninsured if the ACA is
repealed do not have at least an associate degree.

To be clear, you can’t add up all of the numbers above,
because people at risk of losing coverage could fall in multiple
categories. But no matter how you slice
and dice it, ACA repeal, particularly without an alternative that would cover
as many with comparable benefits and protections, will lead to massive losses
in coverage, touching just about everyone in some way, in some fashion. Yes, there are at least 50 ways you could
lose your health insurance if the ACA is repealed, and probably, many more.

Today’s question: What is your reaction to the data on how
many could lose coverage and benefits, and in what way, if the ACA is repealed?

Wednesday, December 7, 2016

It’s often said that elections have consequences, and this is
especially true of the 2016 election. The election of Donald S. Trump, combined
with continued GOP control of Congress, will rock the health care world,
starting with the GOP pledge to begin to repeal and replace the Affordable Care
Act early in the new Congress.

But it’s not just the ACA: the Trump administration may try
to privatize the VA, end U.S. commitments to reduce emissions contributing to
climate change, reverse Obama’s executive actions on firearms violence
prevention, convert Medicare into a defined contribution (voucher) program
rather than an open-ended entitlement, and much, much more. While these are highly concerning to ACP, we
believe that there will be many opportunities to find common ground on improving
access to mental health, healing the opioids epidemic, reducing barriers to
chronic care management, reforming the medical liability system, and especially,
reducing regulatory burdens on physicians and their patients.

In order for ACP to be effective, we have to start by stepping
back and assessing what the impact of the elections will likely be on our
priorities, recalibrating as needed to achieve our objectives. To be clear, this does not mean stepping back
on our commitment to issues like
universal coverage, mitigating the public health impacts of climate change,
reducing gun violence, and ensuring access to care for all persons without
regard to race, religion, ethnicity, gender and gender identity, and sexual
orientation; these are overarching core principles and policy commitments the
College has made to the public, they can’t be negotiated away. But we can and will assess how best to
advance or defend them given the changed political circumstances.

Here is what your ACP advocacy team in Washington has been
doing to help ACP prepare for the new administration and Congress:

We provided suggestions to ACP President Dr. Nitin S.
Damle on his
November 17 email to all ACP members, U.S. and international, on the
implications of the 2016 election.

We are working with Dr. Damle on responding to several dozen e-mails from members in response to his letter.

We are doing a comprehensive staff assessment of all of our key public policy priorities; for each of them, we are evaluating whether there is a threat or opportunity or threat and opportunity, whether it’s from Congress, the Executive Branch, or both; and whether we need new or revised policy direction from the ACP policy committees, regents and governors.

In particular, we are examining how the GOP may use a “repeal, delay, and replace” legislative strategy to undo as much of the ACA as possible through budget reconciliation, which requires a simple majority vote, while delaying for a couple of years the date(s) when those provisions would expire, which in theory gives them a time to develop a replacement plan (which is much easier said than done, which I will address in a future post).

For some of our priorities, we are doing a much deeper policy dive; for instance, examining possible GOP alternatives to the ACA overall and specific elements of it; the impact of possible efforts to privatize the VA system; implications of turning Medicaid into a block grant program; potential threats to Graduate Medical Education funding; and policies affecting women’s health access, among others.

Our regulatory affairs team is preparing specific recommendations to the new administration and Congress on changes in federal regulations, quality measurement, EHRs and “meaningful use” requirements, documentation guidelines, and on other ways to ease administrative burdens on physicians.

We are reaching out to other health-advocacy organizations, not just within the medical profession, but with business leaders, hospitals, insurers, and consumer groups, to see where our interest may align and where we may differ; and how we might work together when we are in agreement.

We are continuing to encourage members to sign up to participate in our grass roots Advocates for Internal Medicine (AIMn) program while making enhancements to it. The strength of this program will to a large extent determine how effective we can be advocating with the new Congress.

Even as we are devoting so much of our time to prepare for the new administration and Congress, we are ensuring that ACP’s voice is heard now, as the lame-duck 114th Congress completes work on several outstanding health care bills, including the CURES Act and a temporary resolution to fund the federal government into early next year. We are also providing extensive comments to the outgoing Obama administration on the 2017 Medicare physician fee schedule final rule and the MACRA final rule. Oh, and we are developing new and updated resources and tools to help members be successful as Medicare’s new Quality Payment Program (created by MACRA) begins to be rolled out on January 1.

In my view, ACP advocacy is more important now than ever before. On issues ranging from ensuring that internists’ patients don’t lose their health insurance coverage, easing the regulatory burden on physicians, protecting GME from budget cuts, ensuring that women don’t lose access to care, supporting the many ACP members in the VA system and the veterans they serve from ill-advised “reforms’, advocating for medical liability reforms, opposing policies that would be discriminatory against LGBTQ persons, and continuing to advocate for policies to reduce the health consequences of climate change, ACP will be there, ensuring that internists’ voices are heard in this tumultuous time for American (and global) health care.

Today’s question: What policies do you think are most important for ACP to advocate with the new Trump administration and Congress?